Provider Demographics
NPI:1669638011
Name:BERRY, KILEY ANN (OD)
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:ANN
Last Name:BERRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1266 ESCALANTE DR
Mailing Address - Street 2:STE 301
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-8902
Mailing Address - Country:US
Mailing Address - Phone:970-828-2200
Mailing Address - Fax:907-828-2201
Practice Address - Street 1:1165 S. CAMINO DEL RIO
Practice Address - Street 2:SUITE 100
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301
Practice Address - Country:US
Practice Address - Phone:970-247-8762
Practice Address - Fax:970-385-4496
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO2653152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
320059Medicare Oscar/Certification